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A Better System for Preventative Care

Walking into Dental School, I knew I would change the world! Walking out, I had been trained to repair
teeth and make a great smile. Where was the disconnect?! My dental training was excellent, and my
Class II box is a work of art. Now that I look back over the better of two decades as a pediatric dentist,
there was very little discussion that the rest of the body is connected to and influenced by the mouth
and vice-versa. (28, 29, 30) After over a decade and a half of repairing teeth and paying lip service to
prevention, I was not able to stomach the thought of another restoration without addressing the
complete health of the child sitting in my chair. What could I do to take this child that was suffering from
oral disease and change their life without picking up a handpiece? I knew that if we wanted to truly
become preventive that we needed a better system.

Parents are frustrated and tired of repairing cavities in their children’s mouths. According to the CDC,
more than half of children six to eight years old have had at least one cavity in their primary teeth and
more than half of children from 12 to 19 years old have a cavity in their permanent teeth. (1) This
accounts for thirty-four million hours of school missed and an estimated forty-five billion dollars in lost
productivity in the workforce. (2) Children are unable to concentrate in school, sleep at night, etc., all of
which lead to unhealthy children that turn into unhealthy adults.(3,4) From the AAPD, “the
consequences of Early Childhood Caries often include a higher risk of new caries lesions in both the
primary and permanent dentitions, hospitalizations and emergency room visits, high treatment costs,
loss of school days, diminished ability to learn, and diminished oral health-related quality of life.” (5)

How do we move from a society that waits for disease to manifest to a society that prefers to manage
things before they create a problem? I love the phrase “the absence of disease is not health.”

The ADA has recognized that caries is a complex multifactorial disease where “Drill and Fill” is not
adequate for control (6,23). To address this, the advent of Caries Risk Assessment (CRA) has taken shape
over the years. On quick examination I found eighteen different CRA options all with varying criteria.
Featherstone’s research says that no one knows which is best, and predictably, the provider will have to
be the one that decides what to use and how. (7) In our office, to assess risk and prevent disease, we
incorporated the assessment we felt best fit our situation with an interesting modification (which
incidentally Featherstone alluded to). (8)

As a dental professional we were all taught the caries balance between protective and pathological
factors. Everything from buffer capacity and adequate saliva flow on one end, to cariogenic bacteria and
frequent carbohydrates on the other. Objective and subjective risk assessment items were the hurdle we
needed to cross. The subjective information would be everything the parent tells us, accurate or not!
The objective items were always the usual: recent restorations, white spots, etc. How do we impart this
information that shows risk for disease to a person that is not familiar with oral disease or is not
interested? That is where saliva testing in our facility came into play.

As a pediatric dentist I mainly deal with children. The difficult part for me is that children come with
baggage. They are called parents. Fortunately, most parents truly do want the best for their children, but
dentally they often do not know what that is. By showing data with actual measurements, or criteria, we
have been able to engage more parents/caregivers in a way that captured their attention.

The two methods we use involve either a swab of the lingual surface of the mandibular anteriors (for our
non-cooperative patients) or collecting a small volume of expectorated water. The swab gives us a
relative acid content of the plaque in that area, and the expectorated water shows relative levels of
cariogenic bacteria, acidity, buffer capacity, protein, blood, leukocytes, and ammonia. This shows
caregivers a number that takes a vague, nonspecific discussion into a more concrete discussion that 
opens doors we previously were not aware existed. We now have the option, especially with the
expectorant test, to discuss caries risk, inflammation, and relative biome content of the oral cavity and
how that can affect or is being affected by the rest of the body.

Let’s take a quick dive back into all those courses that most of us, barring the strange like myself, have
tried to forget! The microbiome of a child, depending on C-section or vaginal birth, and article you read,
will be similar to the parents during the first year to eighteen months of life. (9,10) Beyond the first year
we start to see deviation as more foods and epigenetics come into play. (11) Why are we waiting until
the parent, especially if they have an unhealthy oral microbiome, transfers that microbiome to the child?
(12) The AAPD recommends we see every child 6 months after the eruption of the first tooth or by age 1.
(31) That works great if we have parents that are healthy with a healthy microbiome feeding their child
the proper foods, etc. That also works if we have all the medical/dental providers providing the
necessary information to the parents at the appropriate times. We as a dental profession need to step
up and demand that to truly prevent future health issues plaguing both children and adults, these issues
are addressed before day one. (13)

Why are we not screening parents prenatally to try and alter what bacteria they are going to transfer to
the next generation? (14) As I do not have a consistent number of women who are pregnant coming to
my office, this screening will require a collaboration between pediatric and general dentists along with
pediatricians, obstetricians, and any other medical or dental provider that they come into contact with.
When we step outside the box, which we have created for ourselves, we will be able to screen for oral
inflammation which has been linked to low birth weight, premature labor, and other pregnancy issues.
(15) While the initial screening gives relative information on caries risk and inflammation, it is low cost
and gives results in less than five minutes. This information can catapult at-risk individuals into more
definitive testing for specific results and interventions.

With the subjective and objective clinical observations, along with salivary information, we have been
able to discuss risk, behavior, and track the progress of the interventions we are using. Each child we see
is unique, and in a unique situation, so placing a blanket prevention program does not work. (16)
With the conversation open and the discussion with parents taking more of a concrete approach, now
we can more effectively discuss the root issues that are causing the decay, inflammation, etc. Counseling
on diet, issues with salivary flow due to medications, nasal versus mouth breathing, inflammatory status
and sleep disordered breathing are just the start of where the conversations have now moved. Early
referral to pediatricians for children that are showing high inflammation in the salivary screening can
now be evaluated for obesity, prediabetes, SDB, UARS, and the list goes on. (17, 18, 19, 20, 21, 22, 24,
25) We now see traction with involving whole family discussions on diet modification to improve health
for the family unit versus focusing on single children. (26, 27) No longer does the phrase, “Grandma/
Grandpa/random person at the store gives them candy all the time” work.

I have heard the question, “Are you preventing yourself out of a job?” If only this were a real possibility!
Assume that we can completely eradicate decay. What would people do with that estimated forty-five
billion dollars in lost productivity? Realistically, we are just setting ourselves up to be the “go to” place for
oral and systemic health. I love the title that Kevin Boyd has coined: Primary Care Dentist. I also love the
idea from Next Level consulting that it’s not a recall but an Oral Health Assessment. Imagine this: Healthy
patients, Healthy practice. Besides, who doesn’t want to look back at the end and say “Wow, I did change
the world”.

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Dr. Boyd Simkins, DDS
Boyd Simkins is a pediatric dentist with a private practice in North Ogden, Utah. He has been in private practice for 18 years and is Faculty in the Post-doctoral Pediatric Dental Residency at Primary Children's Medical Center in Salt Lake City. His passion in dentistry is improving the health of every child he and his team come in contact with and bridging the gap between medicine and dentistry for the next generation of providers